=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215254834
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COVENANT SMILES DENTAL CARE AND LABS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2010
-----------------------------------------------------
Last Update Date | 04/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 WAVERLY PKWY
-----------------------------------------------------
City | OPELIKA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36801-3311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-740-1632
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 WAVERLY PKWY
-----------------------------------------------------
City | OPELIKA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36801-3311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-740-1632
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. FRANK LAMBERT WRIGHT
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 334-740-1632
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5270
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------